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BACKGROUND: Skin and soft-tissue infections (SSTIs) are a common complication of military training. Naval Special Warfare (NSW) training requires prolonged periods of extreme physical exertion and unique environmental exposures, including extended immersion in ocean water. A centerpiece of SEAL training is referred to as "Hell Week" (HW), a colloquial term to reflect the intense physical obstacles and exposure to extreme environmental conditions endured by candidates. Due to such environmental exposures, NSW trainees are at increased risk for SSTI due to uncommon organisms. A prior outbreak of Shewanella SSTI and bacteremia among NSW trainees led to the initiation of prophylactic doxycycline 100 mg daily during and for 7 days after HW to attempt to reduce this risk. The efficacy of this intervention is undetermined. METHODS: Doxycycline prophylaxis was initiated in August 2015. We conducted a retrospective analysis of SSTI incidence presenting for medical attention among NSW trainees from April 2013 to November 2018, using case records collected prospectively at the Naval Special Warfare Center. The incidence of SSTI was calculated based on the size of a given class and the number of affected trainees. SSTI cases were then divided and analyzed as occurring during vs. after HW. RESULTS: The pre-intervention cohort consisted of 1626 NSW trainees. A total of 76 trainees developed SSTI, with 20 cases during HW and 56 cases in the post-HW period. In the post-intervention cohort, 2022 trainees experienced a total of 81 cases of SSTI during HW and 83 in the post-HW period. 45% of all SSTI cases occurred in the months of June, July, and August. The incidence of cellulitis between the pre- and post-intervention cohorts during HW was 2% and 4%, respectively, and 5% and 6.4% in the post-HW period. There were no hospitalizations for invasive gram-negative infections following the initiation of doxycycline prophylaxis. CONCLUSION: Doxycycline prophylaxis does not appear to reduce the incidence of SSTI but may reduce the ...

BACKGROUND: Older travelers (≥ 60 years) are a unique risk population for travel related infections and adverse events from antibiotics. We evaluated the differences in travel characteristics, exposures, illnesses and antibiotic use among older travelers and those between 18 – 59 y using a prospective, observational cohort of US Department of Defense (DoD) beneficiaries traveling outside the US for ≤ 6.5 months (TravMil). METHODS: Adult DoD beneficiaries were enrolled pre-travel. Itineraries limited to Western/Northern Europe, Canada, or New Zealand and active duty personnel on military travel were excluded. Demographics, itineraries and prescriptions were abstracted. A post-travel survey collected information on exposures and illnesses (travelers' diarrhea (TD), influenza-like illness (ILI) or febrile illness). Categorical variables were analyzed using chi-square or Fishers exact test and the Mann-U Whitney test was used for continuous variables. RESULTS: Of the 1468 travelers, 755 were ≥ 60y and 719 were < 60y. Asia (35%) and South/Central America (28%) were the most common travel regions. Older travelers were more likely to be Caucasian (80% vs. 67%), male (52% vs. 39%) and travel for tourism (84% vs. 51%) (p< 0.05). Younger travelers were more likely engage in risk behaviors (e.g. consume poorly cooked meat or seafood (16% vs 9%) or street vendor food (26% vs 8.6%), wade in fresh water (24% vs. 18%), and non-compliance with malaria prophylaxis (22% vs 12%) (p< 0.05). Older travelers had a lower incidence of TD (18% vs 24%), and a higher proportion of cases with loose stool or mild TD that did not interfere with daily activities (63% vs. 51%) (p< 0.05). Inappropriate antibiotic use for loose stool or mild TD were similar among the two age groups (67% vs 59%). Non-significant trends of lower incidence and mild infections were observed for ILI and febrile illness in older travelers. CONCLUSION: Older travelers were less likely to engage in risk behaviors, had a lower TD incidence and reported mild ...

BACKGROUND: Increasing international travel places larger populations at risk for infections outside of their usual exposure. Deployed military personnel have unique risks for such infections. Our cohort's rates of travelers' diarrhea and influenza-like illness have been defined, but the rate of travelers with symptoms apart from a clinical syndrome has not. We present a survey of intra-travel symptoms of all travelers and confirmed diagnoses of ill-returned travelers in a cohort of military and civilian travelers. METHODS: TravMil is a prospective, multicenter observational study enrolling US military beneficiaries traveling outside the continental United States from 2010–2018; beneficiaries could also enroll after travel if they presented for a possible travel-related illness. Demographic information, intra-travel symptoms, and confirmed diagnoses were recorded. RESULTS: 2671 travelers embarked on 3050 trips: 63.1% male; median age 38 years (IQR 27, 57); median trip duration 20 days (IQR 13, 46). Common purposes of travel: military deployment (45.9%), vacation (23.7%), and visiting friends/relatives (10.9%). Ninety-seven travelers (3.2%) enrolled post-travel. Top regions of travel: Africa (31.5%), South and Central America/Caribbean (25.5%), and Southeast and North Asia/Oceania (19.4%). During travel, 56.6% experienced gastrointestinal (GI) symptoms, 11.9% respiratory symptoms, and 3.0% fever; of those, 10.3% sought medical care. Eighty returned travelers sought medical care (21 prospective enrollees vs. 59 post-travel enrollees): 5 vs. 17 malaria cases, 3 vs. 16 arbovirus infections, and 6 vs. 14 GI syndromes. All malaria cases in prospective enrollees were in military subjects. Post-travel enrollees accounted for 1 acute human immunodeficiency virus and 3 rickettsial infections. CONCLUSION: A majority of our travelers experienced symptoms during travel. Post-travel diagnoses, although uncommon, emphasize needed improvements in the application of known risk mitigation strategies. Our findings can help ...

BACKGROUND: Travelers' diarrhea (TD) is a leading threat to military readiness. Most trials of rifaximin chemoprophylaxis involve civilians or short-duration travel, whereas military travelers are exposed for longer periods at austere locations and are often physically taxed. We sought to assess efficacy of two regimens among military personnel deployed overseas. METHODS: This was a multi-site, double-blind, placebo-controlled trial of deployed military, randomized to placebo, rifaximin 550 mg daily, or rifaximin 550 mg twice-daily, for up to 42 days (1:1:1; 6 randomizations/block). Diaries were reviewed with subjects on return. Primary endpoint was time to first unformed stool (TFUS) in a TD episode. Other endpoints were assessed by intention to treat (ITT) and subgroups included incidence of any loose stool, meeting criteria for TD, safety, efficacy, adherence and impact to activity endpoints. RESULTS: 343 subjects were included in the ITT population. All UK travelers deployed to a single-site in Kenya; US travelers mostly deployed to various Asia-Pacific locations. Of 73 (21.2%) subjects reporting diarrhea, 42 (57.5%) met TD criteria. Among rifaximin-treated subjects, 15.9% (n=17) reported diarrhea in the twice-daily arm, 20.7% (n=25) in the daily arm, vs. 27.0% (n=31) of placebo recipients; p=.04 and 0.26 respectively. TD was reported by 10.3% (n=11) and 10.7% (n=13) in the daily and twice-daily arms, vs. 15.7% (n=18) among placebo recipients; p=0.24 vs. 0.26 respectively. Among UK personnel, a twice-daily regimen vs. placebo resulted in significantly fewer TD episodes (1.6% vs. 11.9%; p=0.03). Adverse events were similar between groups. Table 1: Demographics, endpoints, and adverse events (Comparisons are across placebo vs. each dosing regimen. Intent-to-treat [ITT] population defined as subjects enrolled into the study, randomized, travelled and had follow-up. p-values calculated from chi-square or Fisher's exact test [categorical variables] and Wilcoxon-Mann-Whitney test [continuous variables]. Analyses ...